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Health at Every Size Programs Decrease Worry about Weight and Refocus Attention on Positive Attributes

Allison Nichols, EdD,
Associate Professor
West Virginia University

Brenda Porter, MS, Extension Instructor
West Virginia University

Terrill Peck, MA,
Extension Instructor
West Virginia University

Kerri Wade, MSW,
Assistant Professor
West Virginia University

Guen Brown, PhDProfessor Emeritus
West Virginia University

Abstract

A group of county-based educatorsconducted a study to examine the impact of participation in a “health at every size” program. Two tools were used to collect pre- and post-data: the A New You assessment tool developed by “WIN the Rockies, WIN Wyoming,” at the University of Wyoming, Cooperative Extension Service and a validated assessment tool entitled “The Body Shape Questionnaire” (Evans and Dolan, 1993). A "A New You: Health for Every Body" workshop was conducted in each of eight rural counties with 98 individuals with 96.7 percent of participants female and 41.8 percent high school educated or less. Participants ranged in age from 30 to 60 years of age and their ages were evenly distributed by decade. Data was collected on the first and last day of eight 10-week sessions. Analyses showed that the program (1) decreases worry about one’s body size and shape (body image) and (2) creates a shift from preoccupation with body size to a focus on one’s positive attributes. Participant comments illustrate the findings. Recommendations are offered for further research and improved practice.

Efforts to undermine the growing obesity epidemic have not been successful, even though fad diets and weight loss advice are readily available on the TV, Internet, and in books and magazines. In fact, according to the Center for Disease Control (Centers for Disease Control and Prevention 2008), 33.8 percent of all Americans are obese and 34.2 percent are overweight. Dieting may not be the answer. In fact, in a meta-analysis of several studies, researchers found that within two years 23 percent of participants in weight loss programs regained the weight they had lost (Tomiyama and Mann 2008). This rose to an astounding 83 percent in studies where participants were followed beyond two years. Provencher (Provencher et.al 2007) found that overweight women, who had realistic weight expectations, tended to be happier (both in general and with their particular body type) and had healthier eating behaviors than those with less realistic weight expectations. Befort et al. (2007) found that the less effort dieters perceived that they needed to make in order to implement their weight-loss plans, the more apt they were to follow through with their plans.

An alternative to the traditional diet has arisen in recent years, namely programs that collectively follow a concept known as “health at every size” (HAES) (Robison 2005). These programs, which arose from the Non-Diet/Size Acceptance Movement, maintain that being thin is not intrinsically healthy and beautiful, individuals naturally have different body shapes and sizes, and dieting usually leads to weight gain, decreased self-esteem, and increased risk for disordered eating (Robison, Putnman, McKibbin 2007). HAES programs emphasize adopting a positive image of one’s body size and encourage physical activity as well as normalized eating, whereas the premise of dieting is that one’s own body is not what it should be, and dieting tends to lead to denial of certain types of food and quantities of food. The premise of HAES is that people of every size can be healthier without giving into the pressures of traditional diets. In short, the program focuses on health rather than weight and on the methods of eating and the internal cues that the body gives, rather than on calorie intake. Since many people eat for reasons other than hunger, such as anxiety, loneliness and boredom, the major goal of these programs is for people to eat only when the body experiences a physiological hunger response and to act upon cues of fullness (Mehrabian 1980; Lyman 1982; Patel and Schlundt 2001; Macht 1999). HAES programs also advocate the use of 30 to 60 minutes a day of purposeful exercise and physical activity for a healthier lifestyle. Many programs have been created to emulate and build on the HAES paradigm around the country, and the USDA has begun to incorporate the HAES paradigm (Drake 2006).

A research study by Bacon and colleagues that examined the efficacy of a HAES approach compared with a "state of the art traditional behavior weight-loss intervention"found that both groups experienced similar physiological and psychological benefits during the six-month intervention; however, after two years, the HAES group maintained almost all of the initial benefits such as improvements in metabolic fitness, eating behavior, depression, self-esteem, and energy expenditure, while the diet group did not (Bacon et al. 2002; Bacon et al. 2005). Research into this area is still in its infancy, but some have begun to explore its potential. “An anti-dieting hunger-based approach to dietary intake shows promise as a potentially effective approach for de-emphasizing culturally dominant beliefs about eating and thinness, normalizing a pleasure relationship with food, and promoting healthy weight management” (Smith and Hawks 2006). A HAES program for hospital staff found that participants demonstrated statistically significant decreases in body dissatisfaction, depressive symptoms, and disordered eating (Robison 200).

A group of Cooperative Extension county-based educators in a rural state with an adult obesity rate of 27.6%, conducted a HAES program, “A New You: Health for Every Body” in eight rural communities in 2006. The group hypothesized that a person who participates in the “A New You: Health for Every Body” program will acquire a more positive body image as a result of participation. This paper reports an evaluation protocol that explored the benefits to rural adults participating in the program.

Methods

Curriculum

“A New You: Health for Every Body” is a health-focused, multi-method, experiential curriculum built around the principles of pleasurable and healthful eating, intuitive eating, enjoyment of physically active living, and respect for body-size diversity. It is part of the Wellness in the Rockies program at the University of Wyoming (University of Wyoming, 2008). The program helps participants move away from unhealthy food and eating attitudes and behaviors into a gentler, non-diet approach to well-being based on enjoyment of active living in a healthy body. The goal is for participants to develop new attitudes and gain knowledge and skills to live and enjoy a healthy lifestyle. The unique aspects of this program are its promotion of “size acceptance” and “health at any size.”

The curriculum is organized into 10 one-hour sessions, with one supplemental lesson; however, there is flexibility for combining and adding lessons and activities for teaching the program in five two-hour sessions. The ten lessons include the following topics: 1) a new approach to health and readiness to change; 2) eating styles and intuitive eating; 3) normal eating and hunger satiety; 4) foods and moods and diet facts; 5) gentle nutrition, fiber, and portion control; 6) making peace with food and finding smart snacks; 7) motivating oneself to move; 8) fitness for every body; 9) mind over media and appearance assumptions; and 10) being the best you can be, self talk, and congratulating oneself. These interactive lessons use a variety of audio/visual media, discussions, and small-group processes. Each lesson incorporates a physical activity break to get participants moving. “Words of Wisdom” or WOW (quotations selected from WIN the Rockies qualitative research), which involve the collection of people’s narratives or life stories are incorporated into lesson topics (University of Wyoming 2010). “On Your Own Learning” activities provide opportunities for participants to practice the concepts taught after they leave the class and prepare for the next class. Participants receive a variety of resources to help them make changes in their attitudes and behaviors related to food, physical activity, and body image.

Tools

Two tools were used to collect data: The A New You body size assessment tool developed by “WIN the Rockies, WIN Wyoming,” and University of Wyoming, Cooperative Extension Service, Department of Family & Consumer Sciences (University of Wyoming 2010) and a published, validated assessment tool entitled “The Body Shape Questionnaire” (BSQ) that measures perception of body image (Evans and Dolan 1993).

The A New You body size assessment tool was developed as part of a larger study to assess attitudes and behaviors in the areas of eating, physical activity and body image, and was tested with randomly-selected group of households in six communities (n=500). Surveys were distributed and collected by the Bureau of Business and Economic Research at the University of Montana, and results of survey were analyzed by researchers at Montana State University. The same survey was randomly sent to households in the 6 communities at the conclusion of the 2-year intervention effort (University of Wyoming 2010). Questions on the WIN the Rockies questionnaire use a four-point scale (1=strongly disagree; 2=disagree; 3=agree; 4=strongly agree). One question about TV watching used a five-point scale (1=never; 2=seldom; 3=sometimes; 4=most of the time; 5=always).

The items on the Body Shape Questionnaire were derived by conducting semi-structured interviews with various groups of women including patients with anorexia nervosa and bulimia nervosa. To validate the BSQ, it was administered to three samples of young women in the community. The validity of the measure was shown to be good (Cooper, et. al, 2006). The Body Shape Questionnaire contains 16 questions that are scored on a six-point scale (1=never; 2=rarely; 3=sometimes; 4=often; 5=very often; 6=always).

Demographic questions were added to the evaluation tool. Research protocol and evaluation tools were reviewed by the university’s Institutional Review Board and received an exemption. Cooperative Extension county-based educators who delivered the program also administered pre-questionnaires at the beginning of the first class as well as post-questionnaires ten weeks later at the end of the final class. Prior to handing out the pre-questionnaires, research procedures were explained. The data was analyzed on SPSS Version 17, using paired sample statistics (t-tests) and principal component analysis (factor analysis) rotated with Varimax with Kaiser Normalization.

Participants

The sample is a convenience sample that includes 98 individuals from eight counties; all participants completed the program in 2006. Participants self-selected to participate in the program and there was no charge for participation. The majority of the participants (97%) were female; only three participants were male. Almost all the participants were white/Caucasian (94%). Participants’ ages were distributed between 30-70 years of age. Table 1 lists participant age categories. Participants were not highly educated; nearly half had a high school education or less. Table 2 shows the educational level of participants. Nearly half of the participants were working full-time (42%) and a fourth were retired (24%). Table 3 shows the employment status of participants. Nearly three-fourths of the participants were living in small households, nearly one-fourth were living alone (23.3%), and almost one-third were living with only one other person (31%).

Table 1. Age Categories of Participants

Age Category

Percent

Under 30

6.7

30 - 49

35.5

50 - 69

47.8

70 or older

10.0

Table 2. Educational Level of Participants

Level

Percent

Less than high school

19.6

High school diploma

41.4

Some college/trade school

24.1

College degree

2.3

Graduate work

12.6

Table 3. Employment Status of Participants

Employment status

Percent

Working full time

42.2

Working part time

11.1

On disability

4.4

Retired

24.4

Unemployed for other reasons

17.9

Results

Perceptions

The answers to 30 questions on the pre-questionnaire were compared to the same 30 questions on the post-questionnaire using paired sample t-tests that compare mean scores on the pre-questionnaire with mean scores on the post-questionnaire. The difference between the mean scores on 13 questions were statistically significant at the p <.05 level and they are listed in Table 4. It is important to note that on the A New You body size assessment we would expect the responses to be more positive after the intervention, therefore the difference between the means should be a negative number, however on the “Body Shape Questionnaire” we would expect the respondents to be less negative about their body. As seen in Table 4, participant perceptions include changes in the way participants viewed their own body (thighs, hips, bottoms, firmness of flesh), changes in reaction to stimuli that, in the past, would have caused them concern about their bodies (boredom, seeing thin women, eating sweets), changes in attitudes about the ideal shape (what others think, shame) and changes in the importance of exercising. Change in one item, “I get as much physical activity as I need,” indicates that participants changed a health behavior during the program: they increased their physical activity.

I have abilities and strengths that are more important than body size.

2.90

3.29

-.39**

.76

Questions from The Body Shape Questionnaire

Pre-mean

Post-mean

Difference in means

Std. Deviation

Has feeling bored made you brood about your shape?

2.85

2.46

.39**

1.12

Have you thought your thighs, hips, or bottom was too large?

3.95

3.32

.63**

1.38

Have you worried about your flesh being not firm enough?

4.05

3.50

.55**

1.25

Do thin women made you feel self-conscious?

3.38

2.88

.50**

1.16

Have you worried about your thighs spreading out when sitting?

3.19

2.48

.71**

1.36

Has eating sweets made you feel fat?

3.65

2.37

1.28**

1.47

Have you felt ashamed of your body?

3.77

3.33

.44**

1.04

Has worry about your shape made you diet?

3.47

3.12

.35**

1.04

*p <.05

**p<.02

Benefits

Benefits to participants in the "A New You: Health for Every Body" program were derived by conducting a factor analysis with the variables in Table 4. Two groups emerged. Table 5 lists the questions that emerged under each group. After examining the variables in each grouping, groups were labeled according to the program benefit they described: group 1 -- the program decreases worry about one’s body size and shape (body image); and group 2 -- the program creates a shift from preoccupation with body size to a focus on one’s positive attributes. Each of the groups was tested for reliability. We are confident that the questions can be treated as a group for the purpose of analysis because the alpha scores were all above .7.

Table 5. Program Impacts

Construct/Group

Questions or Variables that Showed Significant Change

Program decreases worry about one’s body.

Has feeling bored made you brood about your shape?

Have you thought your thighs, hips, or bottom was too large?

Have you worried about your flesh not being firm enough?

Have you felt ashamed of your body?

Do thin women made you feel self-conscious?

Have you worried about your thighs spreading out when sitting?

Has worry about your shape made you diet?

Has eating a small amount of food made you feel fat?

Has eating sweets made you feel fat?

Program helps participants make a shift from preoccupation with body size to an appreciation of other positive attributes.

I feel comfortable with how I look.

I don’t care what people think about my body.

Many different shapes and sizes of human bodies can be attractive.

I have abilities and strengths that are more important than body size.

Discussion

While earlier research found that HAES programs helped participants de-emphasize culturally dominant beliefs about eating and thinness, normalize a pleasure relationship with food, and promote healthy weight management (Smith and Hawks 2006), this research adds two other benefits from the A New Health for Every Body program’s focus on physical activity, healthful and pleasurable eating, and acceptance of one’s body size. Those benefits include a decrease in worry about one’s body size and shape and a shift from preoccupation with body size to an appreciation of other positive attributes and activities. Qualitative data captured from participants’ self-evaluation also confirm these conclusions as illustrated below.

Participation in the program decreases worry about one’s body size and shape.

“I feel better about myself now. Not so hard on myself anymore.”

“I should not worry about my body shape as long as I eat healthy and exercise, smaller portions, recognize when I am full, and get out and walk a little more--well a lot more.”

“I learned not to be putting myself down as much. Being fit and healthy matters.”

“I like myself, no matter what size or shape.”

“I will accept the weight I am when I feel healthy. No more charts. I can and will do this!”

Participation in the program helps individuals make a shift from preoccupation with body size to an appreciation of other positive attributes and activities.

“That I am blessed to have other qualities that are more important than worrying about my shape.”

“I learned to love and accept body size; to not assume that a heavy person overeats.”

“It makes you stop and think just how busy we are and how we don’t take the time for our mind and bodies to be healthy.”

“I learned that I should not deprive myself of something to eat that I really like. Eat it once in awhile.”

The “A New You: Health for Every Body” evaluation team offers the following recommendations for future practice and research:

Future studies should:

Look at long-term changes resulting from HAES programs. One intervention may not change attitudes over the long term, and some people may eventually lapse back into their old ways of thinking. Researchers might also look at what type of person is more likely to make permanent changes.

Examine whether there is a difference between how a person views him or herself and how they think others view them.

Include further comparisons of HAES programs with traditional diet programs.

Examine research questions to be certain they are sensitive to cultural differences and the reliability should be tested. For example, a question about “super sizing” meals did not take into account that rural individuals may not have fast-food restaurants that offer super-sizing. Questions about hips and thighs may not be as relevant to men as they are to women.

Conduct a comparison study of HAES and diets.

Measure differences in dosage and delivery methods.

Health educators should:

Reach out to more young people. The time to address negative attitudes about one’s body and instill healthy habits is when people are young. An HAES intervention, if proven appropriate and acceptable for young people, could make significant impacts on people’s lives. This concept is illustrated best by a quote from one of the participants:

“Reach more young people with this message please! Especially reach younger girls in grade schools and junior high school girls. Even as a college student, I didn't eat right; I starved and felt miserable.”

Include more opportunities in the program format for exercise and encourage pedometer use.

Encourage community groups to incorporate HAES concepts into other health programs

Conclusion

Researchers have found that women who have realistic weight expectations for themselves tend to be happier and adopt healthier eating behaviors than those with unrealistic expectations (Provencher et. al 2007). The strength of HAES programs is that participants develop more realistic expectations for themselves (Robison 2005). The Extension educators who conducted the HAES program described in this paper did so in a rural state known for its high rates of obesity and chronic diseases such as diabetes and heart disease. They hypothesized that a person who participates in the A New You Health for Every Body program would acquire a more positive body image. They found that the benefits of the 10-week program were that the participants worried less about their weight and body size and began to concentrate on other positive attributes such as abilities and talents. Future studies will need to examine whether this effect lasts over time and whether it results in improved health indicators such as weight loss and blood pressure scores.